Cross-Cultural Challenges: Improving the Quality of Care for Diverse Populations

At a major metropolitan area hospital, a man refused to allow any African American employees to help in the delivery of his wife’s baby — and hospital officials acquiesced. The hospital later apologized, but not before local and national media featured the story. At another hospital, a Islamic man whose wife was in labor requested that only a female physician deliver their baby because of their religious beliefs — but there was only a male physician on call that evening. The hospital struggled with what to do next.
These incidents are just a few examples of how the subject of cultural competence "is attracting increased attention given the concern with improving access, eliminating racial and ethnic health disparities, and providing more culturally competent, high-quality care to diverse populations," according to Robert C. Like, MD, MS, a family physician with a background in medical anthropology.
Exploring and Negotiating
But how does one gain it? Dr. Like, who directs the Center for Healthy Families and Cultural Diversity at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, cites the work of Dr. Madeline Leininger and her colleagues. In Transcultural Nursing: Concepts, Theories, Research and Practice (McGraw-Hill, 2002), they describe three cross-cultural care decisions and actions that clinicians and administrators can pursue when working with patients, families, and communities, says Dr. Like:
  • Culture care preservation/maintenance
  • Culture care accommodation/negotiations
  • Culture care repatterning/restructuring

Dr. Like says that the incidents at these hospitals could have benefited from an exploration and negotiation of each of these three possibilities among all of those involved – patients, practitioners, and staff. "A particular caveat is the need to be careful not to stereotype or over generalize about specific populations," he says. "There is often greater diversity within than between groups so that cookbook approaches to care don't work and can be extremely dangerous." He cites two "excellent resources" with helpful cross-cultural clinical case studies and pointers: Dr. Geri-Ann Galanti’s Caring for Patients from Different Cultures (University of Pennsylvania Press, 2004) and Dr. Suzanne Salimbenes’ What Language Does Your Patient Hurt In? A Practical Guide to Culturally Competent Patient Care, from Other Cultures (Diversity Resources, 2000; 1-800-865-5549).


Health care organizations might also wish to consider creating "cross-cultural ethics and mediation committees" that can assist with conflict resolution and policy making, says Dr. Like. "Several years ago, I heard about one hospital that had developed a ‘smudge healing ceremony policy’ in collaboration with members of the American Indian/Native American community that they served," he says. "The important point here is the need to develop authentic relationships and partnerships that are based on mutual trust and respect."
Six Dimensions
Dr. Like cites six questions asked by Dr. Kathleen Culhane-Pera, co-author of Healing by Heart: Clinical and Ethical Case Stories of Hmong Families and Western Providers (Vanderbilt University Press, 2003):
  • On what basis are traditional healers, health care practitioners, and institutions trustworthy?
  • What behaviors demonstrate respect for persons, patients, and families?
  • What are the ideal roles, responsibilities, and prerogatives of patients, families and providers?
  • What health information should be disclosed to whom, and how?
  • What considerations are relevant to assessing a patient's best interests and risks and benefits?
  • What methods and criteria support good health care decision making?


To these, Dr. Like adds one of his own: How should our own professional and personal values, morals, and ethics interface with those of the patients, families, and communities we serve?
"It is vitally important that we examine how various ‘isms’ and ‘phobias’ – ageism, sexism, racism, classism, ableism, homophobia, and xenophobia, to name just a few, have historically contributed to disparities and inequities in access to care, service utilization, quality, and outcomes," Dr. Like says. "These challenging issues must be tackled at the institutional, interpersonal, and intrapersonal levels."

The development of organizational and systemic cultural competence is of critical importance, says Dr. Like, and health care organizations should become familiar with the Department of Health and Human Services Office of Minority Health’s National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care published in the Federal Register in 2000.
Making Sense — and Cents
And addressing cross-cultural ethical conflicts — in other words, gaining cultural competence — isn’t just the right thing to do. It’s good business practice. "A business case is increasingly being made for providing culturally and linguistically competent health care," says Dr. Like, citing "an excellent review" of the business case by Cindy Brach and Irene Fraser ("Reducing disparities through culturally competent health care: an analysis of the business case. Quality Management in Health Care. 2002;10:15-28).
Cultural competence is also related to patient safety and risk management, he says. For example, the Department of Health and Human Services’ Office for Civil Rights published updated guidance on the prohibition against national origin discrimination as it affects people with limited English proficiency. Working with organizations such as the National Council on Interpreting in Health Care, the American Translators Association, and other agencies as well as addressing health literacy issues can facilitate better access to culturally and linguistically appropriate care, Dr. Like says.
An International Effort
Cultural competency efforts are underway not only in the US, but in Europe, Australia, and other parts of the world. Dr. Like suggests that we are all wrestling with some questions:
  • What is our preferred image of diversity — melting pot, salad, rainbow, tapestry, kaleidoscope, mosaic, cauldron, stew, some mix of the above, or another term altogether?
  • What are the implications of each of these metaphors for how we plan, organize, implement, and deliver high-quality, cost-effective services to the increasingly diverse populations we serve?
  • How can we learn to tolerate, respect, and value our diversity, as we collectively seek the common ground that underlies our shared humanity?


"There are no easy answers in our troubled world," he says. Dr. Like says all of these efforts require health care providers and the individuals, families, and communities they serve to develop greater "cultural humility" in their relationships (Tervalon M, Murray-Garcia J: "Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education," Journal of Health Care for the Poor and Underserved 1998;9:117-124).
"Developing cultural competence is a lifelong journey rather than a destination - a verb rather than a noun," Dr. Like says. "Every encounter is a cross-cultural encounter!"


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